Open haemorridodectomy

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Open Haemorrhoidectomy (Milligan-Morgan Operation)

Definition and Background

Open haemorrhoidectomy - most commonly known as the Milligan-Morgan operation - is the standard surgical technique for haemorrhoid excision in the UK and Europe. It involves ligation and excision of haemorrhoids with the wounds left open to heal by secondary intention (unlike the closed/Ferguson technique where wounds are sutured). It was described by Milligan, Morgan, and colleagues at St Mark's Hospital, London.

Bailey and Love's Short Practice of Surgery 28th Edition, p. 1453
Current Surgical Therapy 14e, p. 334

Indications

Large, prolapsing (grade III-IV) haemorrhoids with an extensive external component
Symptomatic haemorrhoids failing conservative/office-based treatments (injection sclerotherapy, rubber band ligation)
Symptomatic haemorrhoids causing significant bleeding leading to anaemia
If there is doubt about the diagnosis, examination under anaesthesia and/or endoscopic visualisation are needed first
Bailey and Love's, p. 1453

Preoperative Preparation

Stool softeners in the days before surgery
Preoperative enema to empty the rectum
General or regional anaesthesia
Patient positioned in lithotomy or prone jack-knife position

Operative Technique (Step-by-Step)

1. Infiltration

The anoderm and subcutaneous tissues between the haemorrhoids are injected with dilute adrenaline (1:300,000 dilution) to:

Reduce bleeding
Aid preservation of skin bridges

2. Grasping and Traction

Artery forceps are applied to the skin-covered external components of the haemorrhoids and traction exerted to reveal the internal components. The three haemorrhoids are removed in order:

Posterior
Left lateral
Right anterior

3. V-Shaped Incision

A V-shaped cut is made through the skin lateral to the haemorrhoid using scissors or cutting diathermy.

4. Dissection

Traction by both operator and assistant, combined with careful dissection, exposes the lower border of the internal sphincter
Dissection proceeds up the anal canal
Sides of the mucosal dissection converge towards the pile apex
The internal sphincter is kept visible and separate from the dissected pile throughout

5. Transfixion Ligation

A transfixion ligature of strong Vicryl (polyglactin) is applied to the pedicle at the level of the apex. The pile is excised well distal to the ligature, and after ensuring haemostasis the ligature is cut long.

6. Secondary Haemorrhoids

If significant secondary haemorrhoids are present under the mucocutaneous bridges, they can be excised by submucosal dissection (Parks technique).

7. Mucocutaneous Bridges (CRITICAL)

After excising each haemorrhoid, it is essential to preserve adequate mucocutaneous bridges between the wounds. At the end of the operation there will be three pear-shaped anal wounds. Failure to preserve these bridges risks anal stenosis.

8. Haemostasis and Dressing

Careful haemostasis is mandatory
A soft absorbable anal dressing is inserted
The wound is covered with moist gauze; no drains are necessary
Bailey and Love's, p. 1453
Pye's Surgical Handicraft 22nd Ed, p. 311

Surgical Illustration

The figure below (from Bailey & Love's) shows the instruments used and the anatomy of rubber band ligation for context; the operative steps for the open haemorrhoidectomy follow the same anatomical landmarks:

Open haemorrhoidectomy anatomy - banding apparatus and banded haemorrhoid

Figure: (a) Barron's banding apparatus. (b) Appearance of a typical banded haemorrhoid showing the anatomical landmarks used in open haemorrhoidectomy.

Open vs. Closed Technique: Key Differences

Feature	Open (Milligan-Morgan)	Closed (Ferguson)
Wound closure	Left open - heals by secondary intention	Sutured with continuous absorbable suture
Geography	UK/Europe standard	USA standard
Wound healing	Longer	Faster
Postoperative pain	More	Slightly less
Outcomes/durability	Similar	Similar

Schwartz's Principles of Surgery 11th Ed, p. 1339
Current Surgical Therapy 14e, p. 334

Complications

Early

Pain (most common; major disadvantage of open technique)
Acute urinary retention
Reactionary haemorrhage (primary)

Late

Secondary haemorrhage (~5% of cases; typically at day 7-10 when the slough separates)
Anal stricture (if mucocutaneous bridges not preserved)
Anal fissure
Faecal incontinence (if internal sphincter damaged during dissection)
Bailey and Love's, p. 1454
Pye's Surgical Handicraft 22nd Ed, p. 311

Whitehead's Haemorrhoidectomy (Historical Note)

A variant - circumferential excision of all haemorrhoidal cushions just proximal to the dentate line, with the rectal mucosa advanced and sutured down. Now largely abandoned due to the risk of mucosal ectropion (Whitehead's deformity/ectropion) - a disabling complication.

Schwartz's Principles of Surgery 11th Ed

Comparison with Other Surgical Modalities

Procedure	Best For	Key Advantage
Open haemorrhoidectomy (Milligan-Morgan)	Grades III-IV with large external component	Most durable; lowest recurrence
Stapled haemorrhoidopexy (PPH)	Grades II-III circumferential, no bulky external component	Less pain, quicker recovery - but higher recurrence
HAL (Haemorrhoidal Artery Ligation)	Grade II-III	Less pain than open surgery; lower recurrence than rubber banding

Bailey and Love's, p. 1454-1455
Harrison's Principles of Internal Medicine 22nd Ed

Key takeaway: Open haemorrhoidectomy remains the gold standard for definitive surgical management of large symptomatic haemorrhoids. The critical technical points are: preserving the internal sphincter during dissection, maintaining adequate mucocutaneous bridges between wounds, achieving secure transfixion ligation of the pedicle, and meticulous haemostasis.

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